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Infertility Concerns among Young Couples in Rural India
Alka Barua1, Hemant Apte2, Rohini P. Pande3, and Sunayana Walia4
INTRODUCTION
As in many developing countries, in India infertility treatment is missing from available reproductive
health services. The Government of India’s public health programme fails to address infertility even
though the International Conference on Population and Development’s (ICPD) programme of
action4, to which the government is a signatory, states that reproductive health services should
include prevention and appropriate treatment of infertility. While national policies and international
donor organizations even today single-mindedly pursue programs to prevent unwanted pregnancies,
they do little to address the needs of childless couples. Although the Indian government in its recent
development and health policies has once again reiterated its commitment to the ICPD programme of
action, and though the government’s Ninth Five-Year Plan (1997–2002) document included
infertility in its comprehensive reproductive and child health package, the primary health care system
has been unable to convert this intent into reality.
In a country like India, where childbearing is considered an essential role in life and a yardstick by
which women’s worth is measured, infertility carried enormous social and emotional burdens. In
particular, the consequences of real or perceived infertility can be harsh for young couples starting
out their married lives. However, while social and individual ramifications of a failure to conceive
are harsh for young couples, there is little research on this group’s experiences with infertility or
their knowledge and exposure to fertility treatments. This paper aims to fill this gap in the literature.
BACKGROUND
In India, the scant data that exists on infertility is surprising considering the likely extent of the
problem. According to WHO, the national prevalence of primary and secondary infertility in India is
3 and 8 percent respectively1. The National Family Health Survey-II, conducted in 1998-99,
estimates that 3.8 percent of women between the ages of 40 and 44 years have not had any children
and 3.5 percent of currently married women are infecund2. Another study carried out in select
Mumbai slums estimates the prevalence rate of childlessness amongst currently married women to be
4.54 percent3.
High rates of infertility are coupled with little or no attention to the issue in India’s health sector.
While there is some rhetoric – including in policy pronouncements – about the need to address
infertility, the public health system still focuses almost exclusively on pregnant women or those who
are trying to prevent unwanted pregnancies. There is little if any counseling or other services
available for the remainder of the women in the reproductive age bracket – those who would like to
be pregnant but are unable to conceive. The neglect of infertility services is not in tune with the
intensity of social expectations for married couples to reproduce and the cultural repercussions when
they fail to reproduce. The stigma associated with childlessness adds to the other emotional
difficulties experienced by infertile couples. The situation is worse for young couples – in much of
India, there is enormous pressure for young couples, particularly women, to prove their fertility
1 Independent Consultant. Email: alki75@hotmail.com
2 Consultant, Foundation for Research in Health Systems, Ahmedabad. Email: hamapte@vsnl.com
3 Independent Consultant. Email: rohinipande@jhu.edu
4 Reproductive Health Specialist, International Center for Research on Women. Email: swalia@icrw.org
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within the first year of marriage. A failure to conceive within months of marriage immediately leads
to concerns and anxiety about infertility.
Gender biases exacerbate this situation for women. The impact of `infertility’ on a couple is largely
determined by gender role expectations in society, and thus the experiences of women may be
significantly different from that of men. In fact, some studies show that gender roles take greater
precedence in shaping women’s experience of infertility than the actual physical problem. That is,
instead of `infertility’ being understood as a socially defined life crisis, it is mistakenly transformed
into an individual (feminine) trait5. Women are made to feel and are more likely to feel anxious,
guilty, frustrated and depressed. Further, women are largely blamed for infertility, and the negative
consequences for them can range from denial of food and health care to being thrown out of the
house so that a man can take a second, presumably more fertile wife (Singh A, Dhaliwal LK, Kaur
A, 1997)
A childless woman is stigmatized not just in the home but also beyond her immediate household.
She is not allowed to participate in various auspicious ceremonies, particularly those involving
childbirth and naming. According to a study in Bhiwandi in Mumbai, “She is called waanj (barren).
There is a superstition that if she touches a baby, the baby will die.” 6 A study in Andhra Pradesh
showed that, anticipating taunts and hostile behaviour from others, many women shun social
functions. They feel isolated and ashamed.7 Abdallah S. Daar and Zara Merali, in their analysis of
infertility and social suffering in developing countries, have designed a framework with a continuum
of the consequences of infertility for women. The levels of consequences range from guilt, marital
and economic stress, depression, violence and abuse, to social alienation, death and lost dignity in
death. Despite this suffering, women’s voices have not found a place in the discourse, even in the
feminist debates surrounding reproductive technology in India.
Men also suffer because of gender norms and there is increasing recognition of this fact. Some
studies have shown that men are equally responsible for failure to conceive. A WHO study of 5,800
infertile couples in 22 developed and developing countries found that men were either the sole cause
or a contributing factor to infertility in more than half of the couples. The same study found that in
only 12.8 percent of cases was infertility due solely to the female with no demonstrable cause in the
male8.
There is some evidence that with technical advancements and increasing awareness that there are
treatments for a failure to conceive, women in India have started approaching qualified medical
providers for help though they still also turn to religious practices for “treatment”. In the Bhiwandi
study6, of 225 cases, 109 childless women sought treatment within one year and all sought allopathic
or religious treatments at some point. However, while women still turn to religion a minority in this
and other studies in India chose religious options as their first choice of treatment.7
In cases where women do not use the services of qualified providers the main reason seems to be the
high costs involved in infertility treatment. In a study in Andhra Pradesh, of the 25 percent of
women who did not seek care, most did not do so because of the high costs (43 percent)7. The
Bhiwandi study showed that women spent anywhere from Rs.20,000 to one to two lakhs on their
treatment.
Studies suggest that many of the above challenges may be countered by the positive impact of
counseling and psychological intervention with infertile couples. In particular, given the extra
burden on women, researchers have proposed three ways infertility care clinics can help women: by
fostering women's self-esteem, by promoting social support networks, and by facilitating the use of
coping mechanisms that reduce distress10. However the counseling skills of service providers in
India are still weak.
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At a UNFPA meeting on how India should address the issue of infertility, a four-tier system of
infertility treatment was proposed. At the community level it involved information & education,
counseling, referrals and support groups. At the sub-health center level it involved taking histories,
performing examinations and making referrals. At the weekly infertility clinic at the primary health
center level, it consisted of conducting systematic infertility evaluations, including cervical mucus
test, semen analysis, basal body temperature, postcoital test, vaginal-smear exam, and laboratory
tests for sexually transmitted infections. At the district hospital level it involved endometrial biopsy,
tubal patency tests, and diagnostic laparascopy, as well as treatment for varicocoele, genital
tuberculosis, endometriosis, and luteal deficiency. The meeting proceedings suggested that the most
advanced technology be offered by the private sector12.
While there are thus a few studies that examine infertility in India, the research on this issue is
limited. In particular, research is limited for young rural Indian couples who are starting out their
married lives, and the specific ramifications for them of being unable to conceive within the socially
expected short timeframe following marriage. This paper addresses this gap. Specifically, this paper
addresses the experiences, concerns, knowledge and health-seeking behavior of young couples in
rural Maharashtra who are struggling with real or perceived fertility problems. We examine their
marital history and obstetric intentions and history to get an accurate picture of what these young
couples perceive as ‘infertility’ and whether and how it deviates from standard medical definitions of
infertility. Further, we investigate their conceptions and misconceptions regarding causes of
infertility, particularly any gender-specific causes, and how this understanding guides their decisions
to seek treatment. We also describe how couples’ experiences fit into, and are coloured by, existing
social and cultural norms around fertility expectations and the resultant taboos surrounding the
failure to conceive.
STUDY DESIGN AND METHODOLOGY
The data are from a community-based intervention research study conducted from 2001 till 2005 in
Ahmednagar District, Maharashtra, India by the Foundation for Research in Health Systems (FRHS),
in collaboration with the State Directorate of Health Services for Maharashtra, and the International
Center for Research on Women (ICRW).
The study tests the effectiveness of community mobilization strategies in improving reproductive
health awareness and use of services by young married women 15-22 years old. The community
mobilization strategy used in the intervention is interactive health education sessions on reproductive
health issues with youth and adults in the community. Following an initial health education session
on causes of and misconceptions about infertility, 110 young couples requested the research team to
assist them with their fertility concerns. Consequently, the research team arranged for a sexuality
counselor to counsel these couples as a first step in the process of seeking treatment. Following this,
the team conducted a study that combines quantitative (79 married young `infertile’ women) and
qualitative methodologies (in-depth interviews with 46 young married `infertile’ women) in order to
examine those women and men who sought the counselor’s services.
This intervention study was preceded by a research phase of formative data collection to inform the
intervention described above. This formative phase ran from 1996 till 1999, during which time
quantitative and qualitative data were collected from young women and their communities around
issues of youth reproductive health. Te data and analyses presented in this paper use primarily the
data from the intervention study, but the formative study is mentioned where appropriate. We use
quantitative and qualitative study data as well as process documentation data from both women and
men in the target age group. The quantitative data comprises background demographic, occupational
and economic information on couples seeking care for infertility and their households. The same
instrument also collected qualitative data on marital history; obstetric intentions and history;
respondents’ perceptions of social and cultural norms around fertility and the failure to conceive;
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their own experiences of support or mistreatment by family and society because of these norms and
their failure to conceive; respondents’ knowledge and perceptions regarding a failure to conceive;
and details of the process undergone to seek treatment, including providers chosen, reasons for
choices made, experiences with care, costs of seeking care, involvement of other family members,
and respondents’ perceptions of quality of care. The process documentation data comes from the
counseling sessions and provides an overall picture of concerns, fears and misconceptions regarding
infertility. The predominant part of the analysis in this paper is qualitative; quantitative background
data are used to explore any demographic or economic patterns among respondents.
We define ‘infertility’ from a community perspective. Specifically, we define infertility as any
perceived failure to conceive on the part of a respondent. While this is not the medically recognized
definition of infertility, it nonetheless reflects actual experiences of couples in our study area who are
trying to conceive. Thus this definition allows us to examine the relevance of medical definitions of
infertility to rural communities and to compare the deviation between medical and cultural
understandings of infertility.
FINDINGS
Who were these couples?
We conducted in-depth interviews with 46 couples who had perceived or experienced infertility.
These couples were largely from non-poor, joint family households. The majority was in their
twenties, educated and had been married for at least six years. The large number of couples in this
age group is not surprising because individuals are more likely to express fertility concerns if they
remain childless as they grow older or are married longer.
Table 1: Profile of respondents
N=46
%
Married to a relative
Yes
58.7
<1 year
4.3
1-3 years
28.3
4-5 years
15.2
Years of marriage
6+ years
52.2
Wife
<18
6.5
18-20
32.6
Current age
21+
60.9
<18
67.4
18-20
23.9
Age at marriage
21+
8.7
Illiterate
19.6
Primary
8.7
Secondary
63.0
Education
HSSC+
8.7
A troubling initial finding is that more than two-thirds of the women in the study were married
before the age of 18, the legal age at marriage. We found that early marriage was common across
the castes and educational status of the respondents. During the course of our project work in the
Ahmednagar area, we found a high level of awareness about the issue of early marriage and its
relevance in the timing of first pregnancies. Early marriage in rural areas tends to lead to the natural
expectation of early child bearing, usually within the first year of marriage. If a child is not
conceived quickly, couples face pressure and stigma from their family and the community. Many of
the young couples interviewed voiced their views on the pressures of early marriage and early child
bearing and their perceived inability to control these aspects of their lives. As one young husband
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noted, “In rural area you are expected to have child within a year of marriage. Inability of the wife
to conceive results in not just humiliation of the wife but also exposes the man to ridicule and
innuendos.”
What are young couples’ experiences of infertility?
The health education sessions in the FRHS program discussed the biomedical definition of infertility
(defined as a failure to conceive within three years of regular intercourse, without using any
contraception) and when the concern for inability to conceive should arise. About one-third of the
women were concerned about failing to conceive soon after marriage. Several of them had already
begun to face repercussions from their families and communities as a result of this perceived
infertility. Many such women, even if legally married, were not accepted as a legitimate wife
because of their failure to conceive. As one respondent noted, “A woman should conceive in the first
year because as long as she doesn’t have baby, she is not totally accepted and integrated in the
marital family.” At the very least, young married women who were childless faced constant
taunting. To quote one woman, “Such women have to face the taunts of their in-laws as well as of
the community made in jocular manner but sharp enough to hurt. This is my own experience.”
Even if, as was true in several cases, the husband was not unduly concerned about the delay, women
worried because they endured most of the familial and social disapproval resulting from a failure to
conceive. Our data also showed that this disapproval quickly took the form of extra work, denial of
food, violence, as well as attempts at a second marriage for the husband. As a 17 year old girl
married for less than 3 years stated, “My husband says it’s Ok. We have not committed any sin so we
will have children. But I am sure he faces taunts from his friends. He never talks about these things
with me. I am worried that if I don’t conceive soon my in-laws will wait for a little more time and
finally opt for his second marriage. That time they will throw me out of the house.”
The desperation of the women in the study was obvious at the counseling sessions facilitated by
FRHS. In some instances, this desperation appeared to drive them to aggressively find fault with
their husbands, blame their husbands, or complain about financial conditions that made it difficult to
access infertility treatment, even though husbands faced similar pressures to prove fertility. One
such husband, driven to tears during the course of the interview, said, “Marnaryacha hat dharta yeto
pan bolnaryacha tond dharata yet nahi.” (One can hold the hand of the person and stop him/her from
hitting, but how can one hold the tongue of one who is abusing verbally).
Data from the interviews as well as process documentation from the counseling sessions illustrate the
role of family elders. These elders, particularly mothers-in-law, were frequently more anxious than
the young couples themselves and tried to insist on being present during the couple’s counseling.
This is a particularly problematic scenario in the case of younger couples or those who have been
married a short time. Younger couples or those married for less than 5 years mentioned in interviews
that though they themselves were not very anxious about not yet having conceived, their anguish
stemmed from familial and community pressure. When asked whether they could stand up to friends
and family members who pressured them, the common response was, “We cannot hurt our family
members by saying that this is our very personal matter and we do not want to discuss it with others.
Having a child is not a personal matter in rural communities.”
Nonetheless, there were examples of supportive families, in which parents, husbands, or in-laws
were concerned in a constructive manner. For example, one respondent noted, “I am married for 3
years and I have not conceived as yet. My mother is extremely concerned and worried. She takes me
for treatment. My in-laws are equally worried. Whenever I say that I have to go the clinic, they ask
me to drop what I am doing and encourage me to go. Half the expenses for these visits are borne by
my in-laws.”
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Case Study:
Priya (name changed) is a 25 year old, literate woman who has been married for the past 7
years. Her husband, Shrikrishna, is 32 years old and an undergraduate working at a medical
store. Priya and Shrikrishna had a daughter four years ago after which Priya has had three
induced abortions because of female foetus. Repeated abortions led to an `injury’ in her uterus
and she has not been able to conceive for the past year. Priya consulted a doctor who advised
her to take certain medicines and observe abstinence. Priya’s husband is willing to undergo
sterilization but this is unacceptable to his parents and elder brother. They want Priya to seek
treatment so that she can bear a male child and they are willing to spend any amount of
money on this. Priya came to the infertility counseling sessions to seek help for her situation.
She believes that a woman without a son, for all practical purposes, is ‘infertile.’
What is the role of gender in these experiences?
Both the qualitative data and the experiences during the counseling sessions clearly demonstrate how
gender biases and inequalities feed into anxiety about `infertility’ among women. In traditional
societies women are largely blamed for a couple’s failure to conceive. Further, in a society where a
woman’s status depends on her bearing children, particularly male children, being labeled `infertile’
condemns her to a life of ignominy. Women perceived as infertile are considered outsiders to the
accepted roles for women: neither a Virgin, nor a Widow, nor a Savashna (married woman). Such
social and gender norms curb the rights of participation in familial and societal activities for women
who fail to conceive as expected.
Our data showed that gender norms in study communities influence the very definition of infertility.
Qualitative data shows that often a woman considers herself `infertile’ until she gives birth to a son.
Thus, some of the couples who came for counseling had only daughters, including some who had
aborted female fetuses. Despite being able to conceive, these couples insisted on participating in
counseling meant specifically for `infertility,’ asking for assistance in conceiving a male child.
Gender norms also play a role in marital relations in the context of being unable to conceive.
Specifically, men do not remain untouched by the repercussions of a couple’s inability to bear
children. Since young women do not have the power to publicly counter the repercussions of
infertility, their desperation often leads to increased strain and aggression within the marital
relationship. For instance, in the counseling sessions, one woman stated upon entering the room,
“See our reports and confirm who is at fault?” Though she had been diagnosed with an irregular
menstrual cycle and problems with ovulation, she wanted to press the point that her husband had a
low sperm count and that this too contributed to their infertility. However, his results were not
discussed at home to safeguard his self-respect and she was solely blamed for their infertility. The
counseling session gave her the opportunity to bring this hidden struggle and her distress into the
open.
Transcripts from the counseling sessions also reveal high levels of anxiety and a tremendous lack of
information about fertility and conception among men. For instance, men’s concerns about possible
causes of infertility included queries about the relationship between fertility and the size of the penis
or duration of intercourse, coital positions to facilitate conception, and the possibility of extramarital
affairs to turn an azoospermic man into a ‘fertile’ man. While in rural communities, in day-to-day
life and particularly in their sex life men usually have the upper hand, in cases of infertility this
power dynamic seemed to weaken considerably, with the result that men voiced the need for
reassurance from their wives about their sexual abilities. Many of the husbands even used the
counseling sessions as an opportunity to ask their wives for feedback on their `performance.’
Among the men in our sample, frustrations resulting from an inability to conceive in the first few
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years of marriage and resultant family pressures were reflected in decreasing interest in coitus and
coital frequency, and in a few cases even in impotence.
These pressures resulted in some men resorting to lies to cover up their childless state. One 36-year
old childless woman recounted her experience: “My husband, whenever asked about not having
children, says that he has a wife and two children who stay in Mumbai. I am his second wife but I
know for a fact that his first wife died long ago. When he is drunk he says that if he had children he
would not have become a drunkard.”
What did couples perceive as the causes of infertility?
Despite some fact-based understanding of fertility, traditional beliefs as well as misconceptions
about “normal” fertility persisted in the study couples. On the one hand, there appears to be some
degree of awareness about the fertile period, the physiology of conception and other aspects of
fertility among more than three-fourths of the women interviewed. At the same time, about one-third
of these women talk about `palna’ being responsible for the delay in conception. Palna is a local
term used to explain a perceived natural spacing among women, believed to perpetuate within the
same family, whether natal or marital, and across generations. For instance, if an older woman in the
community is known to have had a long period between marriage and first birth, a similar delay in
first conception is expected and accepted in the case of her daughters and daughters-in-law. But even
with the explanation of palna, there remains some disquiet about the delayed pregnancy.
Aside from traditional beliefs, superstitions regarding fertility abound, and even educated young
women talked about an exposure to ‘evil’ influences as the cause of difficulties in conception.
Finally, women attributed their inability to conceive to practical constraints. More than two-thirds of
the women in the study lived in joint families, typically in small, one room houses. The privacy
available to a young couple in these circumstances is, at most, afforded by a curtain shielding them
from the rest of the family. Sometimes even pets sleep in the same room. Thus, a few women
expressed the inability of the couple to have regular intercourse or the husband to perform sexually
in these conditions, resulting in failure to conceive.
Where had couples sought care in the past?
The care sought by sample couples depended not only on their awareness of infertility and the
availability of facilities, but also on the perceived causes of infertility. The fear of supernatural
forces or an “evil” influence strongly affected treatment-seeking, especially in its initial stages.
Women often believed that their inability to
conceive was on account of “Devache adave
aale” or divine interferences. They did not
expect guaranteed results from remedial
rituals but still took them very seriously.
Thus, any treatment usually began with
rituals to appease a local female deity
believed to both positively and negatively
influence women’s fertility. In these rituals,
called “maulaichya khetya,” the woman in question went to the temple on a prescribed day, such as
on the day of the new moon, and made offerings to the deity that were symbolic of fertility, such as
green bangles, a sari and blouse piece, fruits and coconuts. The offerings were then retrieved and
given to a woman who had children. These rituals were repeated for at least seven consecutive new
moon days or as per the prescription of a magico-religious practitioner, and were thereafter expected
to bear results within a few months. Women also fasted on certain auspicious days of the week
Table 2: Awareness of young women
Baseline
2001
Endline
2005
N=
911
1010
Medical reasons for Infertility
27.9%
75.4%
Period before seeking Tt
18.9%
38.5%
Partner Tt
69.4%
93.0%
Tt available at Govt. centres
55.3%
79.3%
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reserved for worshipping goddesses considered symbols of fertility, and with powers to control
fertility. Finally, women sometimes went to `Pir’ or Dargahs (Muslim religious places) to pray. A
few women in the study also approached reputed `fertility’ experts in distant areas. The methods
used by such providers were neither known nor discussed by the women who go to them.
At the baseline survey conducted in 2001, we found limited awareness about the need for partner
treatment for infertility, the availability of relevant services, medical causes of infertility, and the
time period after which treatment should be sought.. The health education sessions under the
intervention study specifically focused on addressing these awareness gaps. By the endline in 2005,
the awareness had substantially increased for all these indicators (Table 2). However, the sessions
could not convince participants that they should wait to seek treatment or consider themselves
infertile only if they did not conceive after cohabiting for a minimum of 2 years with the partner
without using any contraceptive. The concern about conceiving within a year of marriage continued
to be prominent. The sessions were not able to overcome the prevailing social compulsion to seek
treatment for infertility if a woman did not conceive within the first year of marriage.
However, qualitative changes were
seen in seeking care. Data collected
during the first, formative phase of this
study in 1996 showed that only 7.8
percent of respondents had sought
treatment for infertility. Of these 3
percent had gone to a Devrishi for
advise and 2 percent had made
offerings to the goddess. Only 3
respondents consulted private doctors, all gynaecologists, for the inability to conceive. The advice to
take these steps invariably came from the elder females in the family, usually the mother. The
experience at the private doctors was by and large satisfactory, except that respondents complained
that the treatment was expensive and did not show quick results. Respondents reported spending
more than Rs. 1500 on the treatment to promote conception. By the endline of the study in 2005,
while the proportion of perceived infertility had come down to 7.6 percent from 32 percent, the
proportion of couples who went to formal health services providers for treatment increased more
than three-fold (from 7.8% to 24.7%). However, during the course of infertility health education
sessions, the importance of `counseling’ was stressed on and as these services were conspicuously
weak in the government sector, the use of government centers for infertility care remained nil.
Either simultaneously with seeking divine intervention or when all else failed, women and their
husbands went to qualified providers, often gynecologists recommended by others who had been
successfully treated. While some were advised by these providers to undergo investigations such as
a blood test, urine test, semen test, sonography or laparoscopy, others preempted the provider,
undertook investigations themselves, and approached a provider with the results of these
investigations in hand. A little more than one-third of the women who sought formal care underwent
“investigative dilatation and curettage.”
Both men and women, however, were largely ignorant of what they should expect when seeking
fertility treatment. In fact, couples commonly misperceived investigative procedures as treatment
and expressed disappointment at not conceiving after procedures such as curetting and diagnostic
laparoscopy. Women who had undergone curetting as a part of infertility treatment described their
disappointment thus: “Mazi pishavi donda dhuvun zali tari pan kahi vilaaj zala nahi.” (My uterus
was cleaned twice but it did not help). Counseling about infertility causes, investigations, treatment
and coping mechanisms was virtually non-existent. Perhaps because of this lack of knowledge about
fertility treatments and the time period that may be required for conception, and the absence of
counseling that could address this lack of knowledge, couples typically switched providers if the
Table 3: Treatment Seeking
Formative
phase
1996
Baseline
2001
Endline
2005
N=
302
911
1010
Nulliparas
32%
17.7%
7.6%
Took Tt for Infertility
7.8%
14.9%
24.7%
Tt at Govt. centres
0.0%
8.3%
0.0%
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woman did not conceive within 2 to 3 months. Since they did not know enough about the diagnostic
or treatment protocols they had undergone, they usually failed to communicate the details of their
treatment-seeking to their new provider. Thus, each new provider tended to repeat previously
attempted and unsuccessful investigations or protocols. Consequently, none of these measures
tended to satisfy the couples.
During the formative phase in 1996,
husbands explicitly indicated a reluctance to
seek medical help for infertility for either
self or wife. At the same time anxiety in the
event of non-conception within a year of
marriage was displayed by practically all.
The baseline shows some – though limited-
involvement by husbands. By the endline,
male involvement in terms of discussing the issue, deciding in favour of care or treatment,
accompanying, paying for and actually taking treatment themselves significantly increased since the
baseline.
DISCUSSION
Our study clearly highlights the cultural expectation in this population that a woman should conceive
within the first year of marriage, irrespective of her age at marriage. Quick conception is proof of
womanhood and hence the pressure to prove fertility is exerted equally by women’s mothers
concerned for the safety and well bring of their daughters in the husband’s household, and by
mothers-in-law concerned about the continuation of lineage or the birth of an heir. Our analysis also
shows that though legally a woman may be a member of the marital family, her assimilation into the
family depends on her bearing a child.
Gender-unequal norms mean that women suffer a disproportionate share of the burden of anxiety and
blame in infertility. Gender issues play out in two ways in the context of infertility. One is the
existing norm in which a woman is not considered `fertile’ until she gives birth to a male child. The
second is the practice of holding a woman solely responsible for the inability of a couple to bear
children or to bear male children. Our findings showing the interaction of gender norms with
societal expectations of young couples to bear children quickly after marriage suggest that services
or programmes designed without taking into consideration the socio-cultural context or gender norms
in which women live fail to address women’s constraints and fail to evoke appropriate responses
from the community.
Our study, while confirming the excessive burden on women because of gender norms, also
highlighted the perspectives of men. Men experiencing childlessness also suffer socially,
physiologically and emotionally, though their concerns are often not allowed to surface in a male
dominated society. While not disputing the gender imbalance that contributes to worse
consequences for women, the study brings out the value of also addressing couples as a whole, rather
than men and women separately. That is, both partners face consequences that need to be addressed
if young couples are to understand their perceived infertility.
Managing and providing appropriate and adequate health care for infertility cases is challenging.
This study demonstrated that despite some levels of awareness and knowledge about causes of
infertility among young couples, the influence of superstitious beliefs in ideas about infertility
remains strong. Biomedical models and concepts have not been able to overcome these traditional
belief systems with awareness raising and availability of services. This may again be because health
programmes are designed independent of the cultural context. In almost every case in this study,
respondents provided an elaborate description of several religious rituals performed by infertile
Table 4: Male Involvement
Baseline
2001
Endline
2005
N=
911
1010
Discussed
33.9%
54.3%
Decided for care
65.3%
91.5%
Accompanied wife for Tt
69.4%
78.7%
Paid for treatment
65.3%
83.0%
Took Tt
3.8%
10.4%
DRAFT: please contact authors if want to cite or quote (rohinipande@jhu.edu or alki75@hotmail.com)
couples, mostly by the women, over a long period of time. Though many of the younger, educated
couples we surveyed may not believe in these rituals they do not challenge the customs for two
reasons. First, they do not believe that rituals and modern medicine are mutually exclusive. Second,
they fear repercussions for not appeasing god or overcoming an `evil’ influence.
In addition to clashing with traditional beliefs, the under use of infertility management also stems
from the required investment over a long period of time in most cases. This tends to increase a
couple’s anxiety. In the words of a provider, “The couple’s life becomes dominated by temperature
charts, blood tests, and endless waiting in clinics. We have to deal with it.” This anxiety and agony
itself may lead to impaired fertility by increasing conflict between a couple and decreasing the
frequency of intercourse, and possibly even impairing sperm quality9.
Our study looked mainly at the experiences, concerns, knowledge, misconceptions and health-
seeking behavior of young, rural, Indian couples with fertility problems within the possibilities and
constraints of their larger socio-cultural context. We also examined how young couples’ beliefs
guide their decisions to seek treatment, and what they experience in this process. This study
contributes to the research on infertility by providing detailed, community-level data on the
experiences of infertility among young couples; the relationships between physiological
manifestations of the failure to conceive and the social and cultural environments in which these
young couples live; and directions on how to engage these couples, their families and communities,
and the health system constructively in finding solutions to their fertility concerns. Findings from
this study are already being used to train state and local level government health providers in
Maharashtra state in counseling, treating and referring young couples with fertility concerns.
ACKNOWLEDGEMENTS: We thank Kathleen Kurz and Kerry MacQuarrie at ICRW for
comments. A special thanks to Saranga Jain at ICRW for excellent editorial assistance and
comments.
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